below, those users include, but are not limited to, physicians and nurses delivering care to patients. The committee followed three steps suggested by the continuous quality improvement model to develop its vision of an improved patient record and record system: (1) identify the customers; (2) understand their requirements; and (3) translate those requirements into functional characteristics of the system (Donabedian, 1966, 1988; Batalden and Buchanan, 1989; Berwick, 1989). 1

Patient Record Users

The committee broadly defined the users of patient records as those individuals who enter, verify, correct, analyze, or obtain information from the record, either directly or through an intermediary. All users of the patient record ultimately support patient care. They differ, however, in how and why they use the record.

Some users have daily contact with the record, others access the record sporadically, and still others never actually handle the record but rely on data derived from it. An exhaustive list of patient record users would essentially parallel a list of the individuals and organizations associated directly or indirectly with the provision of health care. Patient record users provide, manage, review, or reimburse patient care services; conduct clinical or health services research; educate health care professionals or patients; develop or regulate health care technologies; accredit health care professionals or provider institutions; and make health care policy decisions. All of these kinds of users are ''customers" of the patient record, and their needs should be met by patient record systems of the future.

Users are individuals, but they most commonly perform their functions on behalf of institutions. Boxes 2-1A and 2-1B identify types of individuals and organizations that rely on patient records or the data they contain. These lists are illustrative rather than comprehensive and indicate the wide range of users and settings in which patient records are employed.

The full array of patient record users and the respective needs of each were too extensive for the committee to address fully. Therefore, it identified five major categories of users that it considered the most significant and representative. Specifically, the committee focused on practitioners (physicians,

1

As stated by Juran (1989), the remaining steps of the quality improvement process are as follows: (4) design a system capable of supplying these functional characteristics; (5) implement the design; (6) prove the value of the system; and (7) stabilize or further improve the system, depending on the results of ongoing evaluation. Given the scope of its charge, the committee stopped short of designing such a system; it did, however, accomplish an intermediate step by determining the technological implications of the functional requirements of future patient record systems (see Chapter 3).

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